Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> P <br /> NIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number 7 <br /> WASTE MANIFEST C.4f1QW11B141 004 C 2 1 JJK <br /> venerator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ShM12700 00 <br /> Drive 2376 W.Grw t Lkw Rned <br /> Houston.Tx 77067 Tracy,CA 415378 <br /> Generator's Phone: � l eu Ston <br /> 6.Transporter 1 Company ame U.S.EPA ID Number <br /> AltM{a(1Cart Irtagrlbad.S�s Inc LM"1483V <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> V90(o C-S Tschr11C SrikAbOM <br /> CA4D0086W2W <br /> 17Qy West Fast Stmt <br /> A&M.CA 91702 <br /> Facility's Phone: 62&•334-5117 <br /> 9a, 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> 13,Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity Wt.Nol. <br /> 0 1' NA3017,f1avydcKm WesW SoW,txts,9,KA DM P 352 D018 <br /> W <br /> W 2 RUEivV�u <br /> 3. <br /> 4. <br /> Special-Handling Instructions and Additional Information <br /> ____ . . _ _-. rC a try. <br /> ww nlpptn ISto whits t W orvokxmi wa approArneb�. ( /F - <br /> Hoses&NWABermw <br /> JobOM27 fW Pr~136187 Pr45-W <br /> '7 -4n ci Q <br /> 15. GENERATOWSIOF ROR'S CERTIFICAftk I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/ acarded,and are in a�✓respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that e conten§,Qt�onsignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste mi n statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a smalquantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Signature �- j Month Day Year <br /> AS On behat of SC-PA-J ShwiTw ` 1 <br /> _J 16.International Shipments <br /> i— ❑Import to U.S. ❑Export from U.S. Port of en4lqq <br /> exit: / <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials F - <br /> Trans orter 1 Printed/Typed Name ,%7 Signature/;'/ Month Day Year <br /> Cn <br /> Q Transporter 2 Printed/Typed Name I t_Sig6ature Month Day Year <br /> f- <br /> 18.Discrepancy <br /> 18a:Discrepancy Indication Space ❑ Quantityy <br /> E:1T pe El Residue El Partial Refection 1:1 Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> E5 <br /> a+ Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z_ <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prnted/TypedName / Signature Month Day- Year. i <br /> EPAFonn 870MZ(R6.3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />